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ContextOutcomes after cardiopulmonary resuscitation (CPR) remain poor. We have spent 10 years investigating an "informed assent" (IA) approach to discussing CPR with chronically ill patients/families. IA is a discussion framework whereby patients extremely unlikely to benefit from CPR are informed that unless they disagree, CPR will not be performed because it will not help achieve their goals, thus removing the burden of decision-making from the patient/family, while they retain an opportunity to disagree.ObjectivesDetermine the acceptability and efficacy of IA discussions about CPR with older chronically ill patients/families.MethodsThis multi-site research occurred in three stages. Stage I determined acceptability of the intervention through focus groups of patients with advanced COPD or malignancy, family members, and physicians. Stage II was an ambulatory pilot randomized controlled trial (RCT) of the IA discussion. Stage III is an ongoing phase 2 RCT of IA versus attention control in in patients with advanced chronic illness.ResultsOur qualitative work found the IA approach was acceptable to most patients, families, and physicians. The pilot RCT demonstrated feasibility and showed an increase in participants in the intervention group changing from "full code" to "do not resuscitate" within two weeks after the intervention. However, Stages I and II found that IA is best suited to inpatients. Our phase 2 RCT in older hospitalized seriously ill patients is ongoing; results are pending.ConclusionsIA is a feasible and reasonable approach to CPR discussions in selected patient populations.

The Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) is a hybrid of the Mediterranean and DASH (Dietary Approaches to Stop Hypertension) diets, and its association with renal outcomes remains unclear. In the REasons for Geographic and Racial Disparities in Stroke (REGARDS) cohort, diet data were collected at baseline using food frequency questionnaires. Modified Poisson regression was used to examine the association of MIND diet with incident chronic kidney disease (CKD). In the REGARDS stroke case-cohort, 357 metabolites were measured in baseline plasma. Weighted linear regression was used to test associations between MIND diet and metabolites. Weighted logistic regression was used to test associations between MIND-associated metabolites and incident CKD. Mediation analyses were conducted to determine whether metabolites mediated the relationship between MIND diet and CKD. A higher MIND diet score was associated with a decreased risk of incident CKD (risk ratio 0.90, 95% CI (0.86–0.94); p = 2.03 × 10−7). Fifty-seven metabolites were associated with MIND diet (p < 3 × 10−4). Guanosine was found to mediate the relationship between MIND diet and incident CKD (odds ratio for indirect effects 0.93, 95% CI (0.88–0.97); p < 0.05). These findings suggest a role of the MIND diet in renal outcomes. [ABSTRACT FROM AUTHOR]

BackgroundKidney disease disproportionately affects minority populations, including African Americans and Hispanics; therefore, understanding the relationship of kidney function to cardiovascular (CV) outcomes within different racial/ethnic groups is of considerable interest. We investigated the relationship between kidney function and CV events and assessed effect modification by race/ethnicity in the Women's Health Initiative.Study designProspective cohort study.Setting & participantsBaseline serum creatinine concentrations (assay traceable to isotope-dilution mass spectrometry standard) of 19,411 postmenopausal women aged 50 to 79 years who self-identified as either non-Hispanic white (n=8,921), African American (n=7,436), or Hispanic (n=3,054) were used to calculate estimated glomerular filtration rates (eGFRs).PredictorsCategories of eGFR (exposure); race/ethnicity (effect modifier).OutcomesThe primary outcome was the composite of 3 physician-adjudicated CV events: myocardial infarction, stroke, or CV-related death.MeasurementsWe evaluated the multivariable-adjusted associations between categories of eGFR and CV events using proportional hazards regression and formally tested for effect modification by race/ethnicity.ResultsDuring a mean follow-up of 7.6 years, 1,424 CV events (653 myocardial infarctions, 627 strokes, and 297 CV-related deaths) were observed. The association between eGFR and CV events was curvilinear; however, the association of eGFR with CV outcomes differed by race (P=0.006). In stratified analyses, we observed that the U-shaped association was present in non-Hispanic whites, whereas African American participants had a rather curvilinear relationship, with lower eGFR being associated with higher CV risk, and higher eGFR, with reduced CV risk. Analyses among Hispanic women were inconclusive owing to few Hispanic women having very low or high eGFRs and very few events occurring in these categories.LimitationsLack of urinary albumin measurements; residual confounding by unmeasured or imprecisely measured characteristics.ConclusionsIn postmenopausal women, the patterns of association between eGFR and CV risk differed between non-Hispanic whites and African American women.

ObjectiveThis study aims to determine whether menopausal symptoms differed between women with chronic kidney disease (CKD) and women without CKD, and whether CKD modified associations of late vasomotor symptoms (VMS) with mortality and/or cardiovascular events.MethodsCKD, defined as estimated glomerular filtration rate lower than 60 mL/minute/1.73 m (using the Chronic Kidney Disease Epidemiology Collaboration equation), was determined in 17,891 postmenopausal women, aged 50 to 79 years at baseline, in the multiethnic Women's Health Initiative cohort. Primary outcomes were presence, severity, and timing/duration of VMS (self-reported hot flashes and night sweats) at baseline. We used polytomous logistic regression to test for associations among CKD and four VMS categories (no VMS; early VMS-present before menopause but not at study baseline; late VMS-present only at study baseline; persistent VMS-present before menopause and study baseline) and Cox regression to determine whether CKD modified associations between late VMS and mortality or cardiovascular events.ResultsWomen with CKD (1,017 of 17,891; mean estimated glomerular filtration rate, 50.7 mL/min/1.73 m) were more likely to have had menopause before age 45 years (26% vs 23%, P = 0.02) but were less likely to experience VMS (38% vs 46%, P

1. Participants will be able to define the concept of connectional silence (CS) and identify the criteria used to subcategorize CS in the context of telemedicine palliative care consultations. 2. Participants will understand the differences in telemedicine versus in person connectional silence (CS) and the impact on measurement of CS with human coding and computer algorithms. Despite its significance, research on connectional silence (CS) in telepalliative care is limited. This study addresses this gap. Combining human coding and machine learning, it explores CS prevalence and subtypes in telehealth, offering insights into enhancing empathetic care delivery. Connectional silence (CS) in palliative care conversations fosters comfort and trust and is linked to better quality of life and decision-making. COVID-19 highlighted the role of telehealth however it is unclear if CS is present or different in telehealth compared to in-person communication. We sought to determine the prevalence of CS in telepalliative care using dual human and computer approaches. We studied participants from the "Telemedicine facilitated palliative care consultations in rural dialysis study," who were recruited between 2018-20 from five dialysis units. A human coder identified silence defined as pauses of ≥ 2 seconds with no utterances from audio files. Pauses were double-coded as CS and sub-categorized as invitational, emotional, or compassionate. Next, CS were identified using an established computer algorithm based on convolutional neural networks and random forest machine learning methods. 39 participants (90% non-Hispanic White, 56% male) were recruited and 34 participants completed a telepalliative care consultation recorded via Zoom. Intra-rater reliability for CS was 93.5%. Human coding identified 666 pauses of ≥ 2 seconds and computer coding identified 360 pauses of ≥ 2 seconds, with 151 pauses identified by both methods. Among human-identified pauses, 57 (8.6%) were CS. There were 43 (75.4%) invitational CS and 10 (17.5%) emotional CS. CS was identified using human and established computer algorithms during telehealth palliative care consultations with patients receiving dialysis. The prevalence of CS in these teleconsults was similar to a reported prevalence for in-person palliative care. Invitational CS was more common in televideos than in prior work, which may be due to the conversational and technical aspects of telehealth. We confirm the presence of CS in telepalliative care conversations using human and computer coding approaches, which supports the use of telehealth for palliative care delivery in rural settings. [ABSTRACT FROM AUTHOR]

The article "Perspectives from Rising Stars at the R13 NIA/AGS Conference on Resilience Biomarkers" discusses a conference that brought together senior and junior investigators to explore resilience biomarkers in older adults. The conference focused on defining resilience, discussing the biology of resilience, factors influencing resilience biology, and biomarker testing. The group highlighted key features of resilience biomarkers and recommended categorizing them based on stressors. While no universal biomarker panel was identified, recommendations were made for different types of resilience biomarkers, including circulating, physiologic, psychosocial, and imaging biomarkers. The group emphasized the importance of measuring biomarkers across different scales and dimensions to enhance understanding of resilience. [Extracted from the article]

The article discusses the increase of kidney dialysis patients with lower functional status and greater comorbidity. Topics include the mortality rate adjusted for patients in dialysis, the implemented strategy of palliative care to patients brought in an in-center hemodialysis unit and the benefits in maintenance dialysis.

Introduction: Vasomotor symptoms (VMS) are common menopausal symptoms and the timing of these symptoms, specifically onset of late VMS, has recently been linked with cardiovascular risk factors. Chronic kidney disease (CKD) affects 13% of all women in the US and carries high risk for cardiovascular disease (CVD). The association between CKD and VMS has not been studied. Hypothesis: We hypothesized that the timing of VMS would differ between women with CKD compared to women without CKD. We also hypothesized that CKD would modify the effect of VMS on all-cause mortality, coronary heart disease and stroke. Methods: We studied the Women's Health Initiative (WHI) biomarker cohort, which is comprised of all black and Hispanic participants in the WHI observation study and clinical trials plus a subset of white WHI participants such that the biomarker cohort reflects the age distribution of the HT population. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73m and VMS was defined as self-report of hot flushes and night sweats. We used polytomous logistic regression to determine the cross-sectional associations (unadjusted, demographics-adjusted and multivariable-adjusted between CKD and reported VMS categories (none, early, late, persistent). We used Cox proportional hazards models with an interaction term to determine whether the association between late VMS and all-cause mortality or incident CVD was modified by CKD. Results: Among the 18,024 WHI participants, 1281 women (5.86%) had CKD. VMS were less common in women with CKD versus without CKD (37.6% vs 45.8%, p<0.001). Prevalent CKD was associated with an OR of 0.85 (95% CI: 0.72, 1.00) for early VMS, OR 0.80 (95% CI: 0.66, 0.97) for late VMS, and OR 0.59 (95% CI: 0.50, 0.70) for persistent VMS, as compared to having no VMS. The overall association of CKD was not significant after adjusting for potential confounders (p=0.17). CKD was associated with increased risk for mortality (HR 1.72, 95% CI: 1.52, 1.95), coronary heart disease (HR 1.60, 95% CI: 1.33, 1.92) and stroke (HR 1.49, 95% CI: 1.18, 1.87). Late VMS were associated with increased all-cause mortality (HR 1.16, 95%CI 1.04, 1.30) but not significantly associated with coronary heart disease or stroke. No significant interactions were found between late VMS and CKD on any of the endpoints studied. Conclusions: In this multiethnic cohort, VMS were less common in women with CKD and CKD did not appear to modify the association between VMS and either incident CVD or total mortality. [ABSTRACT FROM AUTHOR]

Objective: This study aims to determine whether menopausal symptoms differed between women with chronic kidney disease (CKD) and women without CKD, and whether CKD modified associations of late vasomotor symptoms (VMS) with mortality and/or cardiovascular events., Methods: CKD, defined as estimated glomerular filtration rate lower than 60 mL/minute/1.73 m (using the Chronic Kidney Disease Epidemiology Collaboration equation), was determined in 17,891 postmenopausal women, aged 50 to 79 years at baseline, in the multiethnic Women's Health Initiative cohort. Primary outcomes were presence, severity, and timing/duration of VMS (self-reported hot flashes and night sweats) at baseline. We used polytomous logistic regression to test for associations among CKD and four VMS categories (no VMS; early VMS-present before menopause but not at study baseline; late VMS-present only at study baseline; persistent VMS-present before menopause and study baseline) and Cox regression to determine whether CKD modified associations between late VMS and mortality or cardiovascular events., Results: Women with CKD (1,017 of 17,891; mean estimated glomerular filtration rate, 50.7 mL/min/1.73 m) were more likely to have had menopause before age 45 years (26% vs 23%, P = 0.02) but were less likely to experience VMS (38% vs 46%, P < 0.001) than women without CKD. Women with CKD were not more likely than women without CKD to experience late VMS. Late VMS (hazard ratio, 1.16; 95% CI, 1.04-1.29) and CKD (hazard ratio, 1.74; 95% CI, 1.54-1.97) were each independently associated with increased risk for mortality, but CKD did not modify the association of late VMS with mortality (Pinteraction = 0.53), coronary heart disease (Pinteraction = 0.12), or stroke (Pinteraction = 0.68)., Conclusions: Women with mild CKD experience earlier menopause and fewer VMS than women without CKD.